Data Errors in the Text and Tables
Authors: Anne Schuchat, Gery Guy, Deborah Dowell, Brian Drolet
Journal: JAMA (2017)

In Reply Mr Rudman and colleagues question whether mandatory review of PDMP data reduces opioid overdose death rates.They observe that the 4 states with mandated PDMP policies examined in one study 1 each experienced increases in heroin-related and overall opioid-related overdose death rates from 2011 to 2015.In fact, nearly all states experienced increases in these rates since 1999, including from 2011 to 2015.Therefore, an evaluation of any state-level policy during this period would seem to imply that the policy was associated with increased overdose deaths.To differentiate background trends and other variables across states, Dowell et al 1 used a difference-in-difference regression analysis and compared changes in overdose death rates associated with policies vs changes in rates absent policy intervention.The analysis found that specific policies (eg, mandated PDMP use and pain clinic laws) were associated with reduced prescription opioid-related overdose deaths and overall opioid-related overdose deaths (including those from prescription opioids and heroin).Using this method, these policies were associated with reduced heroin deaths, although this association was not statistically significant. 1 Additional studies have used observational designs to compare opioid-related overdose rates associated with robust PDMP policies with rates expected without these interventions.An interrupted time-series analysis found PDMP implementation was associated with decreased prescription opioid-related and overall opioid-related overdose deaths. 2 Robust PDMP characteristics, such as updating data at least weekly, were associated with greater reductions in deaths. 2 A regression analysis of state-level panel data found PDMP strength, based on combinations of policies including more timely reporting of dispensed prescriptions and mandated use, was associated with decreased prescription opioidrelated overdose deaths. 3 Studies examining the association of PDMP implementation without considering strength of PDMP-related policies have found either no association 4,5 or an association with increased overdoses. 5 These findings suggest that existence of a PDMP may be insufficient and emphasize the need to ensure effective use.Clinician consultation of PDMPs is infrequent when they are available but not mandated, whereas use increases significantly with mandates. 1Timelier data are more clinically useful and might provide greater incentive for clinicians to review them.Clinician burden can be reduced by creating a single sign-on for clinician access to electronic health records (EHRs) and PDMPs, integrating PDMP data into existing workflows, and/or allowing clinician delegates to access PDMP data.Integration of PDMP information into EHRs has been associated with substantial increases in PDMP use. 6 Opioid overdose deaths are increasingly driven by nonprescribed opioids, particularly illicitly manufactured fentanyl.Although findings to date are reassuring that strong PDMP policies do not appear to be associated with increased heroin overdose deaths, 1,2 it is unclear whether they can reduce overdose deaths related to illicit opioids.Unintended consequences of PDMP use, such as dismissal from care, may occur in individual cases.However, consistent use of PDMP information by clinicians can improve patient safety by identifying dangerous medication combinations, high cumulative dosages, or controlled substances obtained from multiple clinicians.Best practices include discussing concerns with patients nonjudgmentally, coordinating care with other clinicians, assessing for opioid use disorder, and offering or arranging medication-assisted treatment if indicated.